Case Report Humeral Shaft Fracture Treatment in the Elite...

Hindawi Publishing CorporationCase Reports in OrthopedicsVolume 2013, Article ID 546804, 5 pageshttp://dx.doi.org/10.1155/2013/546804

Case ReportHumeral Shaft Fracture Treatment in theElite Throwing Athlete: A Unique Application ofFlexible Intramedullary Nailing

Christopher S. Lee,1 Shane M. Davis,1 Hoang-Anh Ho,2 and Jan Fronek3

1 Stetson Powell Orthopaedics and Sports Medicine, 191 S. Buena Vista Street, Suite 470, Burbank, CA 91505, USA2Massachusetts College of Pharmacy and Health Sciences, 179 Longwood Avenue, Boston, MA 02115, USA3 Section of Sports Medicine, Division of Orthopaedic Surgery, Scripps Clinic Medical Group, 10666 North Torrey Pines Road,La Jolla, CA 92037, USA

Correspondence should be addressed to Christopher S. Lee; [email protected]

Received 6 September 2013; Accepted 23 October 2013

Academic Editors: R. A. Gosselin and J. Mayr

Copyright © 2013 Christopher S. Lee et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Humeral shaft stress fractures are being increasingly recognized as injuries that can significantly impact throwing mechanics ifresidual malalignment exists. While minimally displaced and angulated injuries are treated nonoperatively in a fracture brace, themanagement of significantly displaced humeral shaft fractures in the throwing athlete is less clear. Currently described techniquessuch as open reduction and internal fixationwith plate osteosynthesis and rigid antegrade/retrograde locked intramedullary nailinghave significant morbidity due to soft tissue dissection and damage. We present a case report of a high-level baseball pitcher whosesignificantly displaced humeral shaft stress fracture failed to be nonoperatively managed and was subsequently treated successfullywith unlocked, retrograde flexible intramedullary nailing. The athlete was able to return to pitching baseball in one year and iscurrently pitching in Major League Baseball. We were able to recently collect 10-year follow-up data.

1. Introduction

Humeral shaft stress fractures are rare but well-describedinjuries in throwing athletes [1–9]. Baseball players areparticularly at risk of this injury because of their throwingmechanics. Pitchers experience a mean humeral axial torqueof almost 90Nm during maximal external rotation of theshoulder. In addition to axial torque, there is also significantvalgus stress to the humerus. This leads to repetitive stress ofthe humeral shaft as the distal end externally rotates relativeto the proximal end [9]. Consequently, stress fractures mayprogress to displaced spiral fractures of the humeral shaft atthe junction of the middle and distal thirds. With baseballbecoming an increasingly global and year-round sport, theincidence of humeral shaft stress fractures is likely rising.While minimally displaced fractures heal uneventfully,significantly displaced or angulated fractures present asurgical dilemma.

We present a case report where unlocked, retrogradeflexible intramedullary nailing was used in a 17-year-oldMajor League Baseball pitching prospect after failed nonop-erative treatment of a humeral shaft stress fracture. To avoidthe associated morbidity of plate osteosynthesis and rigidintramedullary nailing, closed reduction and unlocked flexi-ble intramedullary nailing was implemented. This techniquehas been described in the pediatric population and in selectadult cases, but to our knowledge and after a literature reviewthis is the first report of its usage in an adolescent, professionalpitching prospect [10]. The patient went on to fully heal hisfracture and successfully pitch in Major League Baseball. Theauthors have obtained the patient’s informed consent for theprint and electronic publication of this case report.

2. Case Report

A 17-year-old left hand dominant male, high school pitcherpresented to the orthopaedic sports medicine clinic after

2 Case Reports in Orthopedics

feeling a pop and severe pain in his left arm while pitching.The injury occurred in the 7th inning of a game during deliv-ery. Prior to that day, the patient had experienced moderatepain in his left arm for 2-3 weeks and self-medicated withNSAIDs. He described no previous trauma to the area. Hewas initially treated at an urgent care facility and was referredto our clinic for further evaluation and management. Priorto the injury, the patient had been scouted by multiple MajorLeague Baseball teams.

Upon physical examination, the patient’s skin was intactin all areas. He had no focal numbness in his left upperextremity and his motor function was intact. The patient hadno significant past medical history. Anterior-posterior andlateral radiographs showed that he had a spiral fracture witha butterfly fragment at the junction of the middle and distalthirds of the humeral shaft (Figure 1). The proximal end ofthe butterfly fragment was nondisplaced; however, the distalend was displaced approximately 1 cm. A CT scan of the leftupper extremity revealed no underlying pathologic process.The history, physical exam, and imaging studies led to thediagnosis of a humeral shaft stress fracture due to repetitivestress. The patient underwent a gentle closed reduction andwas placed into a coaptation splint and sling. Immediatepostreduction films showed excellent fracture alignmentwithonly a 5-degree anterior bow.

At 1-week followup, the patient’s physical examinationwas unchanged. His radiographs, however, showed that theinitial reduction was not maintained. There was now 50%displacement of the fracture in the coronal and sagittal planesand 7–9 degrees of varusmalalignment.While this alignmentis acceptable for many patients, there was concern that forthe elite throwing athlete such malreduction could impairthe patient’s ability to return to high-level pitching. As aresult, after reviewing the diagnosis, treatment options, andpotential risks and benefits with the patient and his family, itwas decided that a closed reduction and internal fixation withunlocked flexible intramedullary nails would be employed tomaintain as much anatomic reduction as possible.

The patient was brought into the operating room andplaced in the supine position. Using a 3 cm long, slightlyposterolateral incision, the lateral aspect of the metaphy-seal flare of the distal humerus was exposed. The extensororigin was reflected anteriorly and the metaphyseal ridgewas identified. Using a 3.5mm drill followed by a 4.5mmdrill, exposure of the intramedullary canal was achieved.The position of the drill holes was confirmed on biplanarfluoroscopy. Two 2.5mm unlocked flexible intramedullarynails were prebent. The first was contoured in a “C” shapefashion while the second nail was “S” shaped. After a closedreduction was achieved in anterior-posterior, lateral, androtational alignment, the first 2.5mm nonlocked flexibleintramedullary nail was introduced into the humeral canal,past the fracture site proximal to the butterfly fragment.The second 2.5mm nail was passed which helped achieve asignificantly improved reduction and stability. The nails werepassed to within 2 cm of the proximal physis. The distal endsof the wires were then cut and bent 130 degrees. They werethen advanced an additional 5mm so that adequate soft tissuecoverage could be achieved. Biplanar fluoroscopy confirmed

Figure 1: Original internal rotation view showing a spiral fractureat the junction of the middle and distal thirds of the left humerus.

excellent reduction of the fracture and proper positioning ofthe nonlocked flexible intramedullary nails (Figure 2). Thewound was irrigated and closed in layers. The patient wasplaced into a posterior splint with instructions to refrain fromweight-bearing and range of motion exercises.

The patient was initially followed weekly for physicalexams and radiographs to ensure proper callous formationand implant stability. One week postoperatively, he wasplaced into a Sarmiento-type fracture brace with continuedsling immobilization. Three weeks postoperatively, gentleelbow and shoulder ROM was initiated. Anterior-posteriorand lateral radiographs at this point showed early callousformation with excellent alignment in the coronal plane anda 20-degree apex anterior angulation in the sagittal plane. At6 weeks, physical examination showed that he lacked about25 degrees of extension and flexed to 135 degrees. Radio-graphs showed abundant callous formation and alignmentremained unchanged (Figure 3(a)). Strengthening exerciseswere initiated along with continued range of motion andstretching. Twelveweeks postoperatively, the patient had nearfull extension compared to the unaffected side and flexed to135 degrees. It was noted that the patient had some irritationover the retained implant; however, a decision was madeto await further healing of the fracture before removal ofthe implant. At six months, anterior-posterior and lateralradiographs demonstrated near full healing with evidenceof remodeling. Due to the continued irritation at the entrypoint of the intramedullary nails, it was decided that theimplantwould be removed.Thiswas subsequently done in theoperating room under general anesthesia. The same incisionwas used to access the intramedullary nails, and they wereremoved using pliers. The patient was protected in a sling fortwo weeks to allow his wounds to heal prior to continuing hisrehabilitation program.

Nine months following his initial surgery, the patientdemonstrated shoulder and elbow range of motion sym-metric to the unaffected side. Radiographs showed excellent

Case Reports in Orthopedics 3

Figure 2: Intraoperative imaging showing excellent closed reduc-tion and internal fixation with nonlocked, flexible intramedullarynails inserted in a retrograde fashion.

healing with maintained alignment. As a result, a short andlong toss program was started. One year postoperatively, thepatient had returned to full pitching duties in game situationsas well as scout leagues (Figure 3(b)).

The patient eventually went on to pitch for a professionalMajor League Baseball team. He was seen and examined10 years following his surgery. The patient stated that hehad one episode of soreness along the lateral humerus andmedial elbow three years following his surgery that resolvedwith rest and rehabilitation. He stated that over the courseof his professional career he has had occasional pain overhis triceps insertion that has been well managed with restand rehabilitation during flare-ups. Physical examination ofthis left upper extremity demonstrated no focal tendernessover the elbow or fracture site. His left shoulder range ofmotion showed full forward elevation and abduction with 5degrees of increased external rotation and symmetric internalrotation compared to the other side. Radiographs taken 10years postoperatively showed fully remodeled healing withnear anatomic alignment in the coronal plane and a 10-degreeapex anterior bow in the sagittal plane (Figure 4).

3. Discussion

The incidence of throwing-related baseball injuries has signif-icantly increased over the past decade [11]. While a thoroughunderstanding of proper throwing mechanics can effectivelydecrease the risk of acute injuries in the overhead throwingathlete, the higher intensity of present training regimentsplaces young athletes at risk of overuse injuries [12]. A rare butpotentially devastating such injury is the humeral shaft stressfracture. While skeletally mature adult throwing athletes areless prone to humeral shaft stress fractures due to corticalhypertrophy and altered shoulder biomechanics, youngeradolescent pitchers do not have this protective physiologicremodeling [7].

Most closed humeral shaft stress fractures without anassociated neurovascular injury can be treated nonopera-tively in the recreational throwing athlete or position player.The management of the elite adolescent baseball pitchercreates an interesting dilemma, however [7]. While thehealing potential in a young, growing athlete is substantial,alterations in the bony anatomy such as an internal rotationmalreduction in a varus can severely inhibit throwing ability.Regardless, it is well accepted that nonoperative therapy ina fracture brace is the first-line treatment modality [13].The options for failed conservative treatment in this specificpatient population are less clear. While open reduction andinternal fixation with compression plating is an excellentoption for the general population, the morbidity of thesoft tissue dissection may significantly impair the abilityof a throwing athlete to return to pitching. Intramedullaryfixation with rigid nails has gained popularity partly becauseit avoids the exposure and periosteal stripping at the fracturesite; however, the trauma to the avascular zone of the rotatorcuff proximally or the triceps tendon distally may compro-mise the thrower’s ability to achieve optimal performance.A third option, nonlocked flexible intramedullary nailing,has had significant success in the pediatric population.The excellent rates of healing are mostly due to the thickperiosteum and significant remodeling potential in the youngpatient population [10, 14, 15]. In addition, compared toadults, children are more capable of regaining their preinjuryrange of motion following fracture fixation [16].

Fewer reports exist regarding the usage of non-lockedflexible intramedullary nailing in the adult population.Hall Jr. and Pankovich conducted a prospective studywhere 89 humeral shaft fractures in 88 patients under-went closed reduction and percutaneous non-locked flexibleintramedullary nailing [17]. In his series, only one fracturewent on to nonunion and there were no malunions orinfections. Average time to clinical union was 7.8 weeks.Postoperative range of motion at six-year followup was −4degrees of elbow extension and 132 degrees of elbow flexion.Shoulder range of motion averaged 91 degrees of abduction,54 degrees of external rotation, and 68 degrees of internalrotation.

While the study done by Hall Jr. and Pankovich showedencouraging results for healing and alignment, the post-operative range of motion is not acceptable for a throw-ing athlete. The authors state that in the cases whereshoulder range of motion was significantly decreased theintramedullary devices had been inserted in an antegradefashion.While their technique avoided damage to the rotatorcuff by making a 6.4mm drill hole 2-3 cm distal to thegreater tuberosity, the nails inserted in an antegrade fashionbacked out in five cases, requiring revision surgery to reinsertimplants. This second procedure potentially led to fibrosisof the shoulder further decreasing the post-operative rangeof motion. The retrograde technique described in the paperdoes not involve any trauma to the proximal humerus, andshoulder range of motion could be initiated two weekspostoperatively.

4 Case Reports in Orthopedics

(a) (b)

Figure 3: (a) External rotation radiograph showing abundant callous formation, maintenance of fracture alignment, and position ofnonlockedflexible intramedullary nails. (b) External rotation radiograph one year after surgery illustrating removal of the implant, remodelingof fracture alignment, and excellent alignment of the humeral shaft.

(a) (b)

Figure 4: Anterior-posterior and lateral radiographs of the left humeral shaft at 10-year followup. The patient has near anatomic alignmentin the coronal plane and a 10-degree anterior bow in the sagittal plane.

A second adult study done by Zatti et al. compared non-locked flexible intramedullary nailing to plate osteosynthesis[18]. This retrospective review followed 14 cases where adulthumeral shaft fractures were fixed with flexible intram-edullary nails and 16 cases underwent plate fixation. Two-yearfollowup showed that the results of elastic nailing, in termsof fracture healing time and functional recovery, appearedcomparable with the results of plating, and complicationsappeared milder.

Both studies stress that nonoperative treatment modal-ities must be first attempted prior to considering surgicalinterventions. In addition, careful patient selection shouldoccur based on patient compliance, age, activity level, neu-rovascular status, and fracture type. The most commoncomplication seen with non-locked flexible intramedullarynailing was related to backing out of the implant. If thisoccurred prior to healing, a revision surgery was necessary.Other complications included post-operative radial nervepalsy, infection, and nonunion.

In conclusion, unlocked flexible intramedullary nailing isa unique and definite option for surgical fixation of humeralstress fractures in the adolescent throwing athlete. In ourcase, a trial of nonoperative treatment with closed reductionand immobilization in a Sarmiento-type fracture brace failedto maintain an acceptable reduction. Careful considerationof the patient’s treatment options led to the decision tosurgically reduce and fix his fracture with unlocked flexibleintramedullary nails using a retrograde technique. We feltthat this method of treatment would reduce the morbidityassociatedwith plate osteosynthesis and rigid locked humeralnailing given the patient’s strong desire to pitch baseball.While the post-operative course was conservative and longin duration, the patient we treated was able to go on to pitchsuccessfully in Major League Baseball.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Case Reports in Orthopedics 5

References

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[4] S. P. Hennigan, C. A. Bush-Joseph, K. N. Kuo, and B. R.Bach Jr., “Throwing-induced humeral shaft fracture in skeletallyimmature adolescents,” Orthopedics, vol. 22, no. 6, pp. 621–622,1999.

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[7] K. Ogawa and A. Yoshida, “Throwing fracture of the humeralshaft: an analysis of 90 patients,” American Journal of SportsMedicine, vol. 26, no. 2, pp. 242–246, 1998.

[8] J. O. Rodriguez, “Humeral shaft fracture in a baseball pitcher,”Current Sports Medicine Reports, vol. 9, no. 5, pp. 292–293, 2010.

[9] M. B. Sabick, M. R. Torry, Y.-K. Kim, and R. J. Hawkins,“Humeral torque in professional baseball pitchers,” AmericanJournal of Sports Medicine, vol. 32, no. 4, pp. 892–898, 2004.

[10] R. I. Huber, H.W. Keller, P. M. Huber, and K. E. Rehm, “Flexibleintramedullary nailing as fracture treatment in children,” Jour-nal of Pediatric Orthopaedics, vol. 16, no. 5, pp. 602–605, 1996.

[11] F. S. Chen,V.A.Diaz,M. Loebenberg, and J. E. Rosen, “Shoulderand elbow injuries in the skeletally immature athlete,” TheJournal of the American Academy of Orthopaedic Surgeons, vol.13, no. 3, pp. 172–185, 2005.

[12] O. Limpisvasti, N. S. ElAttrache, and F.W. Jobe, “Understandingshoulder and elbow injuries in baseball,” Journal of the AmericanAcademy of Orthopaedic Surgeons, vol. 15, no. 3, pp. 139–147,2007.

[13] P. R. Gregory and R. W. Sanders, “Compression plating versusintramedullary fixation of humeral shaft fractures,” Journal ofthe American Academy of Orthopaedic Surgeons, vol. 5, no. 4,pp. 215–223, 1997.

[14] E. D. Leibner, N. Simanovsky, O. Elishoov, E. Sucher, and S.Porat, “Flexible intramedullary nailing for a segmental radialfracture of the neck and shaft in a child,” American Journal ofOrthopedics, vol. 36, no. 1, pp. 23–25, 2007.

[15] T. O’Brien, D. S.Weisman, P. Ronchetti, C. P. Piller, andM.Mal-oney, “Flexible titaniumnailing for the treatment of the unstablepediatric tibial fracture,” Journal of Pediatric Orthopaedics, vol.24, no. 6, pp. 601–609, 2004.

[16] P. Keppler, K. Salem, B. Schwarting, and L. Kinzl, “The effec-tiveness of physiotherapy after operative treatment of supra-condylar humeral fractures in children,” Journal of PediatricOrthopaedics, vol. 25, no. 3, pp. 314–316, 2005.

[17] R. F. Hall Jr. and A. M. Pankovich, “Ender nailing of acutefractures of the humerus. A study of closed fixation by

intramedullary nails without reaming,” Journal of Bone and JointSurgery A, vol. 69, no. 4, pp. 558–567, 1987.

[18] G. Zatti, M. Teli, A. Ferrario, and P. Cherubino, “Treatment ofclosed humeral shaft fractureswith intramedullary elastic nails,”Journal of Trauma, vol. 45, no. 6, pp. 1046–1050, 1998.

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